A nurse is caring for a client receiving a packed red blood cell (PRBC) transfusion. Fifteen minutes after the infusion begins, the client develops sudden chills, severe lower back pain, and dyspnea. Arrange the following nursing actions in the priority order they should be performed, from first action to last.
- 1Stop the blood transfusion immediately.
- 2Disconnect the blood tubing and initiate a normal saline infusion with new IV tubing.
- 3Assess the client's vital signs and respiratory status.
- 4Notify the healthcare provider and the blood bank.
- 5Return the blood bag, tags, and attached tubing to the blood bank.
Answer
The correct priority sequence is to first stop the transfusion, then maintain the IV line with normal saline using new tubing, followed by assessing the client's vital signs, notifying the healthcare provider and blood bank, and finally returning the blood products to the blood bank for testing.
In any acute physiological reaction to an intravenous infusion, the universal first step is to stop the infusion. Once stopped, IV access must be maintained with new tubing and normal saline to allow for emergency medication administration without infusing more of the offending agent. After securing the airway and circulation (ABCs), the nurse assesses the client to gather data, reports this data to the provider for orders, and finally addresses administrative and diagnostic protocols like returning the bag to the lab.
Step-by-Step Solution
Key Concept
Management of Acute Hemolytic Transfusion Reactions